Resident Leadership Grant Application

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Resident Leadership Grant Application - BOG

BOG Spring Meeting, May 5-6, 2013
OTO Advocacy Summit, May 6-7, 2013

Submission Deadline: Monday, April 8, 2013

For U.S. and Canadian Residents only

Visit http://www.entnet.org/bog&summit for information on registering for the BOG Spring Meeting & OTO Advocacy Summit.

I, the undersigned, hereby apply for a Resident Leadership Grant for the 2013 BOG Spring Meeting & OTO Advocacy Summit. If chosen, I understand and agree to accept the terms of an AAO-HNS/F Leadership Grant. I understand that I am responsible for attending the entire BOG Spring Meeting & OTO Advocacy Summit. If I do not comply with these terms, I will be held responsible for repaying the $350 grant to the AAO-HNS/F. Without a valid reason, non-compliance will preclude my training program from receiving travel grants in the future. I understand this information will be tracked through my membership record.

Receipt of this leadership grant may have some tax implications for you. Therefore, it is recommended that you contact your tax advisor to determine your circumstance before accepting the grant. If awarded a grant, please select how you would prefer to receive it (select only one of the bolded options below):

URGENT: Please email Bethany Clifton (bclifton@entnet.org) immediately after you apply for this Resident Leadership Grant to make certain we received your application. This is the first we have used this electronic program, and we need to verify that we are receiving all applications. Thank you.

Pay directly into my account.

Pay directly to my training program institution.

Training Program (Make check payable to):*

Payee's Address 1:*

Payee's Address 2:

Payee's City:*

Payee's State:*

Payee's Zip:*

Payee's Country:

Training Program Director's First Name:*

Training Program Director's Last Name:*

Training Program Director's Email Address:*

Training Program Director's Member ID:

Resident's Member ID:*

Resident's First Name:*

Resident's Last Name:*

Resident's Email Address:*

Resident's Cell Phone:*

Resident's Home Phone:

Resident's Work Phone:

*Resident Signature (By checking this box the resident has agreed to the conditions of this application)

*Training Program Director's Signature (By checking this box the training program director has agreed to the conditions of this application)

For questions contact Bethany Clifton via bclifton@entnet.org or 1-703-535-3736

American Academy of Otolaryngology — Head and Neck Surgery

1650 Diagonal Road, Alexandria, VA 22314-2857

Phone: 1-703-836-4444

Resident Leadership Grant Application - BOG

BOG Spring Meeting, May 5-6, 2013 OTO Advocacy Summit, May 6-7, 2013

Submission Deadline: Monday, April 8, 2013

BOG Spring Meeting, May 5-6, 2013
OTO Advocacy Summit, May 6-7, 2013